Peds Fluid Management Flashcards
T/F Children have small surface area to volume ratio
False
Large surface area to volume ratio
T/F kids have immature homestasis mechanisms
true
What electrolyte abnormalities are common in kids?
Hyper and hyponatremia
Hyper and hypokalemia
Why is pediatric intraop fluid mgmt especially important?
Children overload and dehydrate easily
Considerations if giving large amounts of IV fluids
Need to warm them
Consideration with patient on TPN
Continue perioperatively to prevent hypoglycemia
What age group should you always use volumetric chambers, micro-drips and/or pumps?
Children <10 years old
What two IV fluids can you use with blood products?
NS or plasmalyte
What fluids should you use for maintenance and 3rd space losses?
Non-glucose crystalloids
(LR, NS, plasmalyte)
What electrolyte abnormality can occur with “old” PRBCs?
Hyperkalemia
More common if giving more than one blood volume
Is it appropriate to give platelets if your patient looks a bit oozy but you don’t have any labs?
No
Give for dilutional thrombocytopenia or documented decreased platelet count
What blood product do you give for dilutional coagulopathy or surgical “oozing”?
FFP
What all is considered a colloid?
Albumin
Hetastarch
Blood products
What are some other options besides banked blood for high blood loss procedures that you would prob have to prepare in advance for?
- Autologous donation
- Directed donors
- Cell saver
- Deliberate hypotension
- Normovolemic hemodilution
Is is okay to ride out a low Hct in a healthy, hemodynamically stable patient if they are done losing blood?
Yas
Signs of acute hypernatremia
- Irritability
- Coma
- Seizures
Treatment for hypernatremia
Colloid or NS bolus with slow correction of Na+
Signs of acute hyponatremia
- HA
- Nausea
- Weakness
- Confusion
- Irritability
- Seizures
Signs of advanced hyponatremia
- Respiratory arrest
- Irreversible neurologic injury
Treatment for hyponatremia
Slow correction for asymptomatic cases
Treatment for acute hyponatremia
Rapid correction
~except this causes central pontine myelonolysis?? so SOS~
Causes of acute hyperkalemia
- Renal insufficiency
- Massive tissue trauma
- Acidosis
- Succinylcholine with myopathies, burns, motor neuron disease
- Sepsis
- Massive transfusion
- MH
EKG changes with hyperkalemia
- Peaked T waves
- Prolonged PR
- Wide QRS
- Eventual sinusoidal
Treatment for hyperkalemia
- IV Ca++
- Bicarb for acidosis
- Glucose/insulin
Causes of acute hypokalemia
- Vomiting
- Diarrhea
Signs of hypokalemia
- muscle weakness
- Prolonged QT
- Dampened T waves
- U waves
Treatment for hypokalemia
oral supplements if possible or slow IV correction
What are some reasons for fluid loss intraop?
- Surgical blood loss
- Surgical trauma/capillary leaking protein movement into interstitial space (3rd space)
- Anesthesia–> vasodilation –> relative hypovolemia
- Direct evaporation
If your patient loses 300 ccs of blood how much crystalloid would you give to replace it?
How much colloid would you give?
450-900 crystalloid
300 colloid
Excessive amounts of NS given can cause what electrolyte/ acid base imbalance?
Would this occur with LR also?
Hyperchloremic acidosis
Does not occur with LR
What is a situation where excessive amounts of NS may be given because LR is not an option?
What other fluid could you use in this situation?
With massive transfusion
You can use plasmalyte with blood to avoid hyperchloremic acidosis
Why cant you use LR with blood products?
Ca++ binds to citrate and causes emboli
Two definitions of massive blood transfusion in children
- Replacement of one or more blood volumes
- Replacement of >30 ml/kg in <4 hours
What type of blood should you use in emergency until crossmatched blood is available?
O-
Or O+ in males???
Do you use damage control approach in children
Idk but it has not been fully studied
What is the usual reason for MBT-induced coagulopathy?
Dilution
Other causes: fibrinolysis, DIC
Do you use the fixed ratio of 1:1:1 for blood products on children?
Also not fully researched in children so unsure
What occurs to platelets when 2-2.5 blood volumes are lost?
How to prevent?
Significant thrombocytopenia and further bleeding
- Consider platelet transfusion after 1-1.5 blood volumes
What is a good determinant of platelet needs?
Starting platelet count
What occurs when replacing 1-1.5 blood volumes lost with PRBCs and fluids?
Recommendations to prevent?
Loss of clotting factors
- Consider FFP after 1 BV
- Give FFP after 1 BV loss than 1 FFP: 2 PRBCs
- Check coags after ever BV loss
Recombinant Factor VII (Novo VII) is FDA approved for Hemophilia and congenital factor VII deficiency…
Considerations for off label use in children?
Caution in use for children with surgery or trauma induced bleeding
Should only be used for life-threatening bleeding
Is TXA an early or late choice for bleeding in children?
Early
What should you suspect in children with ongoing bleeding with normal pre-op coags and platelet count?
How to treat?
DIC
Treat the cause (shock, acidosis, sepsis)
What increases risk of hyperkalemia with PRBCs admin?
- Increased PRBC shelf time
- Irradiation
- Fast rate of admin
T/F hyperkalemia is less likely to occur if blood given at slow rate through peripheral IV
True
Most common reasons for hyperkalemia during massive blood transfusion
- Tissue injury
- Rapid transfusion
- Acidosis (poor perfusion)
- Hypothermia
- Hypocalcemia
EKG signs of hyperkalemia in massive blood transfusion
- Ventricular dysrhythmias
- Peaked T waves
Treatment of hyperkalemia
- Calcium
- Hyperventilation
- Bicarb
- Albuterol
- Glucose/insulin
Major considerations for large blood loss
- Anticipate blood loss
- Transfuse early
- PIV if possible
- Minimize use of “old” blood especially if irradiated
EKG signs of hypocalcemia and/or citrate toxicity
- Widened QRS
- Prolonged QT
- Peaked T waves
How to treat documented acidosis?
Bicarb duh
Idk how to word this but dont let your patient get cold when youre giving them all these blood products- treat hypothermia aggressively
kk
What two POC tests are growing in popularity?
TEG and ROTEM
Maintenace IV fluids need for patient under 10 kg?
4 ml/kg/hr
Maintenance IV fluids need for a 4 kg babe
16 ml/hr
Maintenance fluids needed for 10-20 kg kid
40 + 2 ml/kg for each kg over 10
Maintenance fluids needed for a 14 kg tot
48 mls/hr
Maintenance fluids for kid >20 kg
60 + 1 ml/kg for each kg > 20
(or just weight in kg + 40 = mL/hr)
Maintenance fluids for a 35 kg kid
75 mls/hr
How to calculate fluid deficit?
Deficit = Hours NPO x Maintenance rate
What is the fluid deficit for a 32 kg kid that has been NPO for 6 hours?
432 mls
How much fluid is lost to 3rd space in mild level of tissue trauma?
Aka insensible, small incision, scopes
3-4 ml/kg/hr
How much fluid is lost to 3rd space in moderate level of tissue trauma?
AKA ortho, large incision
5-7 ml/kg/hr
How much fluid is lost to 3rd space in extensive level of tissue trauma?
AKA open abdominal or spinal case
>10 ml/kg/hr
EBV for preterm bby
100 ml/kg
EBV for full-term baby to 12 month old
90 ml/kg
EBV for 12 months to 3 years
80 ml/kg
EBV for toddler to 8 years
75 ml/kg
EBV for > 8 years old
70 ml/kg
How much does 10-15 ml/kg PRBCs increase your Hgb
2-3 g/dL
How much blood would it take to raise a 30 kg kids Hgb from 22 to 25?
~450 mls of PRBCs
30 kg x 15 = 450
(can use 10-15 ml/kg for 2-3 increase in hgb)
Calculate MABL for a 6 year old that weighs 22 kg and has a starting Hct of 36
~504 mls
How do you divide up the fluid deficit among the hours of surgery?
Replace 1/2 in the first hour
1/4 in the second and third hour
What is the max amount of fluid the patient should recieve in an hour?
Exception?
What do you do with the leftover?
Do not exceed 20 ml/kg/hour
Exception is if you are replacing blood loss
Roll over the leftover that you couldnt replace to next hour
What is the max amount of fluid a 22 kg patient can get in 1 hour if they arent bleeding?
440 mls
the EKG shows the following:
- peaked T waves
- long PR interval
- widened QRS
what do you suspect?
hyperkalemia
the EKG shows the following:
- prolonged QT
- dampened T waves
- U waves
what do you suspect?
hypokalemia
the EKG shows the following:
- prolonged QT
- dampened T waves
- U waves
what do you suspect?
hypokalemia
the EKG shows the following:
- wide QRS
- prolonged QT
- peaked T waves
what do you suspect?
hint you’re giving bunches of blood
hypocalcemia and/or citrate toxicity w/ MTP